hamstring injuries paul thawley msc, bsc (hons), pgdip (rehab), mcsp srp senior sports...
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Hamstring Injuries
Paul Thawley MSc, BSc (Hons), PgDip (Rehab), MCSP SRP
Senior Sports Physiotherapist Team GB
“Hamstring injuries occur in all sports and effect elite and non elite populations” (Brooks et al 2006)
Athletic Population
Non Athletic population
Epidemiology
FA Audit of Injuries study found that 12% of all injuries reported over two seasons were hamstring strains. (Woods Br J Sports Med 2004;38;36-41)
11-15% Cricket (Stretch 2003, Orchard et al 2002a)
16% AFL with a recurrence rate of 34% Seward et al (1993)
Incidence 0.30 per 1000 playing hours with average severity of 17 days absent in English Rugby Union – Brooks et al (2005)
Epidemiological evidence suggests that hamstring strains are associated with eccentric load, where the contracting muscle is lengthened and there may well be a lack of neuromuscular control.
Biggest risk of injury is previous injury
Biceps femoris most commonly injured
Increased incidence with age
Epidemiology
Posterior Thigh Pain: Differential Diagnosis
Hamstring muscle strain; Acute / Chronic
Hamstring muscle contusion
Referred from Lx
Neural structures; Triggers points
Less Common Posterior thigh painReferred from SIJ
Tendinopathy
Bursitis
Compartment syndrome
Apophysitis
Nerve entrapment
Adductor magnus
Myositis Ossificans
Not to be missedTumors
Iliac artery insufficiency
Diagnosis
Listen Hx is key
LookMove FeelSpecial tests
Neural Dynamics
Slump test as a diagnostic tool
Slump as a treatment modality
Significant effect on Fascia – Vleeming et al 2005
Lumbar Spine
Age / Degeneration of L4/5 and L5/S1 associated with prevalence of hamstring injuries
Successful management of hamstring injuries in Australian Rules footballers: two case reports
Chiropractic & Osteopathy 2005, 13:4 doi:10.1186/1746-1340-13-4
If your think the lesion is soft tissue Dynamic Ultrasound or MRI are you
investigations of choice
Common mechanism Late swing phase in
running action
Eccentric contraction to decelerate the shank
Often accentuated in preparation to jump, kick
Trunk flexion whilst running (Verral, 2005)
Other mechanisms
Stretch with knee fully extended (stretching for a ball, kicking)
Forced trunk flexion with foot planted (waterskiing)
Possible causes of Muscle Injury
Musculoskeletal imbalances
Poor muscular co-ordination
Inappropriate training
Fatigue
Incomplete rehabilitation
Repeated micro-trauma
Musculoskeletal imbalances
Any breakdown in the effective function of the legs and pelvis during running may predispose to injury. Examples include:postural changes due to muscle tightnesslumbar or sacro-iliac joint stiffnesspoor co-ordination of movement or early fatigue associated with muscle weaknessleg length discrepancy (LLD) which will affect pelvic motion and stride length. Note: LLD < 1.5 cm is usually not significantprolonged or delayed pronation or supination of the foot, which will alter the function of the leg and pelvis during the running cycle
Intrinsic and extrinsic factors
Poor muscular co-ordinationRunning requires strength, power, endurance and co-ordination. Problem-free running cannot take place if the hamstrings are weak, inflexible, or if there is poor neuromuscular co-ordination. Loss of the normal ratio of muscle power between the quadriceps and hamstrings may also occur. The normal quadriceps/hamstrings ratio is 60:40. Loss of the normal ratio may be due to excessive development of the quadriceps, or due to existing weakness of the hamstrings. A normal ratio is essential to prevent imbalances from occurring during the running cycle.
Intrinsic and extrinsic factors
Inappropriate training“Inappropriate” comprises all the factors that may affect your body’s ability to adapt to the varied stresses of running. Factors include:excessive mileagerapid increase in mileageinadequate warm-up and cool-downpoor stretchingcambered running surfacesworn shoes or orthotics
FatigueFatigue affects performance and may predispose you to injury. At a physiological level, fatigue may be reflected in a prolonged recovery time at neuromuscular junctions, which diminishes effective muscle activation, slows the clearing of metabolites from the muscle, and impairs the ability of the muscle to contract. Fatigue therefore results in decreased strength, power and endurance, and will increase the risk of injury.
Incomplete rehabilitationAs runners, we are always eager to get back on the road as soon as possible. If an injury is not properly treated, or if you do not achieve your pre-injury levels of strength, endurance and flexibility, the risk of re-injury is increased. Effective rehabilitation (which means putting in the time with the physio, or at the gym) will allow you to get back on the road and stay there.
Repeated micro-traumaOften trauma to the hamstrings may not always be significant enough to cause pain or disability at the time of injury.The reduction in hamstring function may be so gradual that it will not be detected until there is a serious problem. This is often described as “the last straw that broke the camel’s back”, where repeated micro-trauma will finally result in pain and dysfunction. When running, the hamstrings are often exposed to repeated micro-trauma due to over-striding, as well as with a change of pace. Over-striding, particularly when just starting to run downhill, places the hamstrings under excessive eccentric load as the muscle works to stabilise the knee joint. The excessive eccentric load may result in micro-trauma to the muscle fibres, leading to injury.
Treatment approaches
Muscle Injury
What are the consequences to the athlete of not treating a muscle injury correctly?
How much damage is caused by inactivity on the athletes and the doctors part?
Why is there no/little consensus on management of muscle injury?
Staring point with an Hamstring lesion
R.I.C.E
Compression the key
Gentle mobilisation
Partial weight bearing as tolerated
Electrotherapy modalities
When to stretch?When to start running again?
Continued Rx
STR / MFRAcupunctureNSAIDs after 24 hoursElectrotherapy modalities
Correct Physical rehabilitation is paramount in the management of hamstring injuries
Early mobilisation versus strength/stretching Two rehabilitation programs
Static stretching and progressive strengtheningProgressive agility and lumber stabilisation program
No stat difference in RTS times
Stat difference in recurrence rates over I year period remain ISQ (Sherry et al, 2004. JOSPT, 34(3): 116-25)
Where basic science and clinical guidelines collide
Perception is that early mobilisation is against basic principles.
RICE principle for 7 days minimises pain, swelling to offer best possible conditions for healing process. Kannus et all (2003)
Studies cited were for non-contractile tissues (ie ligaments)
Prolonged immobilisation is detrimental
Early mobilisation of affected tissue increases density of scar formation. (Jarvinen, 1975) What about remodelling???
Accelerated running program
Developed by Graham Reid
Australian Hockey Physio
Injured player on tour
Captive audience
Good result
Accelerated Running Program
Day 0:
Ice, Electro modalities, +/- CPM, +/-Ice, Compression etc
Day 1:
Continue as above.
When range in sitting position (Lordotic spine) at 120 or -10 degrees off full knee extension ? start running program
Progressive Running ProgramGraham ReidJogging at variable speed up to 75%
Minimal acceleration/deceleration
Approx 4 min/km pace
Up to 2 kms
Variable distances 100mx3, 90mx3, 80mx3, 70mx3, 60mx3, 50mx3, 40mx3, 30mx3: Repeat x 2
Backwards running: 50 x 3 , 75 x 6, 40 x 3
Progressive Running ProgramGraham Reid
Once at 75% without pain, start acceleration program40 – 20 –4035- 20 –3530-20-3025-20-2520-----2015-----15
Summary of running program
Aggressive but controlled rehab
Takes out a lot of the guess work with training loads
Many variations – needs to be tailored to the sport and then the individual athlete
Addressing causative factors is the most important aspect to hamstring rehabilitation
My approach to pre running criteria (how do you know when the athlete can run ????)
Adductor magnus bridges 5 sets of 12 reps
Seated knee extension = 10 degrees off straight
Single leg long level bridge = pain free
Hamstring Exercises
Manual resistance
Manual therapy
Rehabilitation approach
Why does early mobilisation work?
Eccentric exercise in a controlled way is functional
Improved neural patterning/technical ability
Allows progression as quickly as possible with consistent feedback
CPM effect- decreases disorganised collagen formation. Maintain extensibility of the muscle
Hamstring strains are almost never isolated strains
Strengthening in a functional way
RecurrencesScar at its weakest point 10-12 days after injury
Time frames will vary - forced by time constraints
Analogous to ACL return at 6 months
Injury prevention
Extremely difficult!
Eccentrics???
Concentric Eccentric
Characteristics of eccentric contractionProduces more force than concentricsSelectively recruits Fast fibers. Fast fibers are bigger and have greater potential for growth than slow fibers. During the eccentric phase of movement, the muscle absorbs energy. This work is done “by stretching the muscle and in this process the muscle absorbs mechanical stress This mechanical energy is dissipated or converted into one or a combination of two energies.1. Heat2. Elastic Recoil
Key concepts in injury prevention
Improve the training regime so that it more accurately reflects sports specific conditions with the goal of improving muscle conditioning;
Try and improve fatigue resistance of the hamstring muscle
Try and induce a change in the viscoelastic properties of muscle so as to increase energy absorption and decrease load on the muscle-tendon unit for any given length especially in body positions of function and vulnerability to injury. Verrall et al 2005 Br J Sports Med
Can we predict/prevent hamstring strains?
Previously injured muscles developed peak torque at significantly shorter range than uninjured muscles
Peak torque and quad / hamstring torque ratios were not significantly different
Eccentric exercise possibly shifts length-tension curve to the right
Most Studies used concentric measurements, Why when we know hamstrings have an eccentric action? (Brockett et al, 2004: Med Sci Sports & Ex. 36(3))
Predicting/ Preventing muscle strainsRole of screening
Hamstring range
Strength components (Isokinetic)
Joint ranges
Traditionally, our biggest predictive factor to hamstring strains is previous history of hamstring strain.
Can we predict/prevent hamstring strains?
Decreased incidence in soccer players on an eccentric program
Askling et al (2003): Scand. J. Med. Sci. Sports 13: 244-250
Decreased hours lost, no of injury and weeks out with intervention program (Verral, BJSM 2005)
Incremental Increase in Eccentric ExerciseDrop-catch exercises
(Stanton and Purdam 1989 J Orthop Sports Phys Ther)
Nordic hamstrings
High-velocity eccentric exercises in the final phase of rehabilitation (Geraci 1998)
Hamstring Exercises
Nordic Hamstrings
research From: Bahr and Meahlum (2002)Icelandic curls
Length-tension relationship
Tension
Length
Icelandic curls
Tension
Points to consider in Footballers
Body awareness
Requirements of the Sport
Limited neural aspects
Limited kicking etc. till full running
Ball work restricted in initial stages
Physical rehabilitation does not replace intensive hands-on approach
How to integrated this philosophy with the football management
Sports Specificity relating to hamstring injury prevention
Think specific and genericie FootballLaddersChange of directionBackwards/sideways runningShuttlesChase and escape drills
Recreate load, stress, strain, joint angles, fatigue index
Case Study
Primary hamstring lesion grade 1+ on USDay 1PRICE crutches 2/7 no NSAIDsDay 3STR / PNF local electrotherapy + NSAIDsSeated SLR / passive mobilisationsDay 5 program Active mobilisations / basic gym programDay 7Hamstring specific program (powerpoint)
Case Study Contd
Day 14 Re US scan good reduction in fluid
RTP day 18Post injuryS&C lead eccentric program in place and a physio lead pelvic neuromuscular patterning program with monitoring
Summary
Diagnosis is key, use correct imaging modalitiesInitial treatment is in line with any other soft tissue injury; protection, RICE and early mobilisation.Understand that there is close relationship between hamstring injury, the neural system and lumbar spine pathology
Summary continued
Accelerated running programs can be utilisedIdentify predisposing factors relating to the hamstring injury in that individual athleteApply an eccentric injury prevention strategyDevelop your own strategy related to current research evidenceBe sports specific in your approach
Questions/comments/discussion?
Kyro O la O inen H, Komi PV, Belli A. Changes in muscle activity patterns and kinetics with increasing running speed. J Strength Cond
Res 1999;13:400–6.
Pinniger GJ, Steele JR, Groeller H. Does fatigue induced by repeated dynamic efforts affect hamstring muscle function? Med Sci
Sports Exerc 2000;32:647–53.
Garrett WE. Muscle strain injuries: clinical and basic aspects. Med Sci Sports Exerc 1990;22:436–43.
Best TM. Soft-tissue injuries and muscle tears. Clin Sports Med 1997;16:419–34.
Stauber WT, Knack KK, Miller GR, et al. Fibrosis and intercellular collagen connections from four weeks of muscle strains. Muscle
Nerve 1996;19:423–30.
Stauber WT, Smith CA, Miller GR, et al. Recovery from 6 weeks of repeated strain injury to rat soleus muscles. Muscle
References
References Askling C, Saartok T, Thorstensson A. Type of acute hamstring strain affects flexibility strength and time back to pre-injury level. Br J Sports Med.
2006;40:40-44.
Askling C, Tengvar M, Saartok T, Thorstensson A. Sports related hamstring strains—two cases with different etiologies and injury sites. Scand J Med Sci
Sports. 2000;10:304-307.
Brooks JHM, Fuller CW, Kemp SPT, Reddin DB. Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union. Am J Sports Med.
2006;34:1297-1306.
Connell DA, Schneider-Kolsky ME, Hoving JL, et al. Longitudinal study comparing sonographic and MRI assessments of acute and healing hamstring
injuries. AJR Am J Roentgenol. 2004;183:975-984.
De Smet A, Best T. MR imaging of the distribution and location of acute hamstring injuries in athletes. AJR Am J Roentgenol. 2000;174: 393-399.
Gabbe BJ, Bennell KL, Finch CF, Wajswelner H, Orchard JW. Predictors of hamstring injury at the elite level of Australian football. Scand J Med Sci Sports.
2006;16:7-13.
Garrett WE, Rich FR, Nikolaou PK, Vogler JB III. Computed tomography of hamstring muscle strains. Med Sci Sports Exerc. 1989;21:506-514.
Gibbs NJ, Cross TM, Cameron M, Houang MT. The accuracy of MRI in predicting recovery and recurrence of acute grade one hamstring muscle strains
within the same season in Australian Rules football players. J Sci Med Sport. 2004;7:248-258.
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